OBSTETRICS AND GYNECOLOGY REPORT

Thursday 15th October 2015

Consultant : dr. Eric Edwin, SpOG (K)

Chief : dr. Yudi
Resident : dr. Nas
dr. Ari
dr. Rere
dr. Rochip
dr. Ikhsan
dr. Deki
dr. Yuli
dr. Anti
dr. Arfan
dr. Abi
Resume:
1. Physiologic delivery
2. Patologic delivery
3. Obstetric Major
4. Obstetric Minor
5. Major Obstetric Plan
6. Minor Obstetric Plan
7. ICU
8. Join Care
9. Inpatiens
10. Delivery Room Patient left
11. New Oncologic Patient
12. Oncologic Major
13. Oncologic Minor
 OBSTETRICS MAJOR
1) Mrs. TL, G1P0A0, 39 years old, gestational age 35+2 weeks
Dr. Deki (R4) supervised by dr. Yudi (R7) assisted by dr. Yuli (R3), under
permission of dr. Eric Edwin, Sp.OG (K) had performed SCTP-em b/i fetal
hypoxia, and 2 days PROM, primigravide preterm pregnancy, in 1st stage of
labor active phase
Diagnosis: fetal hypoxia, 2 days PROM, on primigravide preterm pregnancy,
in 1st stage of labor active phase
Male baby was born, BW 2700 gram, Apgar Score: 7-8-9

Chronologies:
G1P0A0, 39 years old gestational age 35+2 weeks, come to RSDM with chief
complain a turbid watery liquid flows from her female genitalia 1 days before
admission. Patient said that she was 8 month pregnant with active fetal
movement. She is already feel womb contraction, a turbid watery liquid flows
since 2 day before admission, with no bloody discharge.
Prior medical history : cardiac disease, hypertension, DM, allergy, and asma were
denied
General condition : In a good state, compos mentis
Vital Sign : BP: 120/80 mmHg t: 36,5oC
HR: 70 X/ minute RR: 18 x/ minutes
Eye : Anemic Conjuctiva (-/-), Ischaemic Sclera (-/-)
Abd : compact, tenderness (-), palpated single fetus intrauterine,
longitudinal, head presentation, back position: left, head unengaged
to pelvic entrance, HIS (-), fetal heartbreat 180x/minute.
Genital : vulva/urethra and vaginal wall within normal limit, portio was
soft, OUE 4 cm, blood (-), discharge (-), amniotic fluid (+), nitracin
test (+)
USG : single fetal was projected intrauterine, longitudinal, back position:
left, head presentation, fetal heartbeat (+), FB:BPD: 9,02; AC:
28,79; FL: 6,41; EFBW: 2730, placental insertion on the uterine
body Grade 1, turbid water. Major congenital abnormality was
unseen clearly.
Summary : G1P0A0, 39 years old gestational age 35+2 weeks, with good
fertility and gynecologic history, palpated single fetus intrauterine,
longitudinal, head presentation, back position: left, head unengaged
to pelvic entrance, inspeculo: livid portio, closed OUE, blood (-),
amniotic fluid (+), nitracin test (+)
2) Mrs. M, G3P2A0, 35 years old, gestational age 35+4 weeks Dr. Vidi (R6)
supervised by dr. Yusri (R7) assisted by dr. Tia (R3), under permission of dr.
Eric Edwin, Sp.OG (K) had performed re SCTP-em, b/i impending eclampsia
in severe pre eclampsia on multigravide preterm pregnancy not yet in labor
with prior Csection 18 years ago
Female baby was born, BW 24000 gram, Apgar Score 6-7-8
Chronologies:
G3P2A0, 40 years old, gestatinal age 33+4 referral patient from Sukoharjo
Hospital, with description G3P2A0 H-32-33 weeks with severe pre eclampsia.
Patient said that she was 8 month pregnant with active fetal movement, watery
discharge unperceived yet, bloody discharge (-). MgSO4 4 gr i.v. and 6 gr drip,
and ceftriaxone 1 gr were given in previous hospital at 13.00.
Prior Medical History: history of hypertension (+) since 2nd pregnancy
DM, asthma, and allergies was denied
General condition : moderate, compos mentis
Vital Sign : BP: 180/90 mmHg; t: 36,2oC; HR: 92 X/ minute; RR: 22x/minute
Eyes : Anemic Conjuctiva (-/-), Ischaemic Sclera (-/-)
Abd : compact, tenderness (-), palpated single fetus intrauterine,
longitudinal, head presentation, back was on the right side, head
unengaged to the pelvic entry, HIS (-), fetal heartbreat
140x/minute.
Genital : vulva/urethra and vaginal wall within normal limit, portio was
soft, diameter unidentified, blood (-), discharge (-), amniotic fluid
(-), amniotic skin unidentified
USG : single fetal projected intrauterine, longitudinal, back position:
right, head presentation, fetal heartbeat (+), FB:BPD: 8,65 ; AC:
28,49; FL: 6,41; EFBW: 2137, placental insertion at the uterine
body grade 1, amniotic fluids was adequate. AFI 9,16. Major
congenital abnormality was unseen.
Summary : G3P2A0, 40 years old, gestatinal age 33+4, with good fertility
history, palpated single fetus intrauterine, longitudinal, back
position: right, head presentation, head unengaged to the pelvic
entrance, inspeculo: livid portio, closed OUE, blood (-), amniotic
fluid (-), EFBW 2137 gram.
 MINOR OBSTETRIC PLAN
1) Mrs. S, P5A1, 45 years old,
Dx:
Et causa placental residual retention, PER in grande multipara with anemia
(7,7), leukocytosis (27,4), hyperglicaemia (233).
Tx: - general condition repairment, blood transfusion until Hb >10
- proposed curretage
- ceftriaxone inj 2 gram/24 hours
- metronidazole inj 500 mg/ 8 jam
- consultation with internist
Operator: dr. Iqbal (R3)
 ICU
Mrs. N, P2A1, 32 y.o
Dx: post C-section, histerectomy, b/i uterine atonia e/c solutio placenta, severe
preeclampsia, HELLP syndrome, IUFD on multipara preterm pregnancy
Tx: Severe pre eclampsia routine procedure
- O2 3 lpm
- RL infusion 12 dpm
- Inj MgSo4 20% 2 gr/hours  24 hours
- Nifedipin 3 x 10 mg if BP >160/110 mmHg
- Observation and evaluation of genereal condition, vital sign, fluid balance,
and eclampsia
- Ceftriaxone injection 2 gram/24 hours
- Metronidazole inj 500 mg/ 8 hours
- Inj Tranexamic acid 500 mg/ 8 hours
- Inj Dexamethasone 2 ampule/ 12 hours

Dx Anesthesiologist : Post C-section b/i placenta previa totalis+ IUFD + Severe

pre eclampsia
Tx Anesthesiologist: - Fasting
- PCT inj 1 gr/8 hours
- Ciprofloxacin 400 mg /12 hours
- Ranitidine 50 mg/12 hours
- Metronidazole 500 mg/ 8 hours
- Tranexamic acid 500 mg/ 8 hours
- Vit K 1 amp / 8 hours

Patient condition this morning

General condition : moderate, compos mentis
BP : 130/80 mmHg
HR : 86 x / minutes
RR : 18 x / minutes with NRM 8 lpm t : 36,7oC
SpO2 :100%
 ONCOLOGY
New Patient
1) Mrs. NR, P1A1 25 years old
Dx: Hypovolaemic shock (resolved) e/c bleeding on high risk PTG with anemia
Tx:
- inpatients
- General condition repairment
- PRC tranfusion till Hb> 10 mg/Dl
- Pro Oncology Consultant Staff examination
- Pro Chemotherapy EMA-CO if terms and conditions were fulfilled

ONCOLOGY MAJOR
1) Mrs. S, P2A0 52 years old dr. Heru P, SpOG (K) with assistant dr Tanjung
(R7) and dr. Rochip (R5) had performed laparotomy exploration b/i ca cervix
grade II A with bladder invasion
Dx pre op: ca cervix I B2
Dx post op: ca cervix grade II A with bladder invasion
Operation report:
6. After peritoneal opening, indentification uterus was done with results: - uterus
shape and size within normal limit - ovarium and both fallopian tube within
normal limit - cervical mass invade bladder wall and subtle to separate
7. Diagnosis was stated: ca cervix grade II A with bladder invasion motivation
and education were given to patient’s family that tumor was unoperable
8. Operation was complete